I n 2000, approximately 10% of the world’s people were 60 years old or older. According to the United Nations Medium Variant population projection, falling fertility and mortality rates will cause this figure to rise to over 20% by 2050. This means that 400 million older people will be living in the developed countries – and over one and a half billion in the less-developed world! Clearly, the interests of the elderly, including their health concerns, are poised to take on greater prominence in coming years. November 2003 The basic diseases which affl ict older men and women are the same: cardiovascular diseases, cancers, muscu- loskeletal problems, diabetes, mental illnesses, sensory impairments, incontinence, and – especially in poorer parts of the world – infectious diseases and their seque- lae. However, rates, trends, and specifi c types of these diseases diff er between women and men. Perhaps more importantly, the gender picture of a given society – the complex pattern of roles, responsibilities, norms, values, freedoms, and limitations that defi ne what is thought of as “masculine” and “feminine” in a given time and place – has a great bearing on the health of the aged. What do we know? The diseases of old age often begin much earlier in life. The conditions that currently account for the bulk of mor- tality and morbidity among older people stem from expe- riences and behaviours at younger ages. Smoking, alcohol abuse, infectious disease, undernutrition and overnutri- tion, poverty, lack of access to education, dangerous work conditions, violence, poor health care, injuries – experi- ence of any of these early in life and throughout the life course can lead to poor health in later years. Since the gender pattern in a given society aff ects the degree to which women and men are exposed to these various risk factors, it has an eff ect on their health in later years, as well. The patterns and impact of the major diseases of the elderly vary between men and women. Cardiovascular diseases (). Since death rates from particular diseases of the heart and circulatory sys- tem are often higher among men than women at specif- ic ages, there is a tendency to think of  as a “male” problem. This is misleading however, as almost eve- rywhere in the world,  is the main killer of older people of both sexes. Among men and women 60 years and older, death rates from  are approximately the same, and, since older women outnumber older men,  actually kills a greater number of older women each year. The importance of focusing attention on  for both sexes is underlined by the fact that these diseases are at least partially preventable, resulting as they often do from smoking, sedentary lifestyles, and diets heavy in cholesterol, saturated fat, and salt, and low in fresh fruits and vegetables. Cancer. Overall, men’s mortality rates from can- cer are some 30–50% higher than women’s, with much (though not all) of this diff erence driven by more lung cancer among men. For men, lung, stomach, and liv- er cancers are the major killers, with colon and pros- tate cancers also important in the developed world. For women, breast and lung cancers are the deadliest over- all. Colon cancer is also important in the developed world, however, while stomach, liver, and, especially, cervical cancers are major killers of women in devel- oping countries. Eff ects of gender and socioeconomic status lurk in these fi gures. For example, the fact that smoking has, traditionally, been a male activity has led to alarming- ly high lung cancer mortality among men. Female lung cancer deaths are on the rise, however, as cigarette advertisers have successfully linked smoking to wom- en’s status and emancipation. In some developed coun- tries, male lung cancer deaths are on the decline, while women’s are still rising. Cervical cancer, on the other hand, remains the deadliest cancer for women in the developing world because eff ective means of screening Gender, Health and Ageing – such as the “Pap” smear – and related treatment serv- ices have not yet become routinely available. Even in developed countries, young women are most likely to receive Pap tests, even though regular screening of old- er women would prevent more cancer deaths. Musculoskeletal problems. For reasons that are not entirely clear, osteoarthritis, the most prevalent musculoskeletal condition among the elderly, is more common in older women than in older men. Osteoporo- sis, or excessive bone tissue loss, is also more common in women. This appears to be linked to hormonal chang- es in women at the time of menopause, but it may be due in part to the more sedentary lifestyles and poor- er nutrition that women, as compared with men, often experience. It is not only lack of exercise that can lead to mus- culoskeletal problems. Disabling conditions are even more likely to be caused by heavy physical labour and unsafe work environments. And reducing the number of crippling accidents among people of all ages – par- ticularly young men, who tend more often to engage in risk-taking behaviour – could also reduce disabili- ty later in life. Finally, falls are an important cause of morbidity and mortality among the elderly. Since women, on average, live longer than men, and are more likely to be poor and thus to live in environments that are dangerous and in ill repair, older women may be especially at risk for falls. Mental health. Most common mental health prob- lems have a higher recorded prevalence in older women than in older men. At least in part, however, this could be an artefact of doctors’ greater readiness to apply a diagnosis of mental illness to women, and/or of fewer men coming forward to ask for help. Despite older women’s higher recorded rates of depression, older men are much more likely than old- er women (and, usually, than younger men) to commit suicide. This may be related to the fact that, in indus- trialized countries, at least, women appear to have stronger social networks and better means of coping than men. Incidence rates for dementia do not appear to dif- fer between men and women. Since, however, women on average live longer than men, there are more older women than older men living with dementia-impaired function. Sensory impairments. While there is currently no evidence that deafness aff ects one sex more than the other, a recent meta-analysis suggests that up to two-thirds of the world’s 40 million blind people may be women. This is partly due to the fact that women, overall, live longer than men, but much of the diff er- ence appears to be gender-related. Women apparently make less use of eye-care services particularly for cata- ract repair surgery than men (due, presumably, to their lower status in the family, restrictions on their public mobility, and their lack of control of economic resourc- es). Also, their role as primary carers for children means that they are more often exposed to trachoma, an infec- tion which, over time, leads to blindness. Incontinence. Urinary incontinence aff ects both sexes. Prevalence appears to be two to three times high- er among older women than among older men, how- ever, due at least in part to poorly treated sequelae of childbearing. Health in old age has to do not only with presence or absence of disease. Availability and quality of care are also important. Most older people, even those in generally good health, will eventually need more care than they did earlier in their lives. The ways societies provide or fail to pro- vide this care can have everything to do with an older person’s quality of life. Does care allow for independ- ence and dignity, but also social connectedness? Is it equitably accessible to all? Who provides it? How is it remunerated? Are the physical and psychological abuse of older people, or other exploitations of their vulner- ability, prevented? These questions are of concern to all older people. Since older women are often more socially and econom- ically vulnerable than older men, however, and since old- er women themselves are more often called upon to be caregivers (see below), the answers may have particu- lar salience for them. Women generally have higher life expectancy than men, but the picture is not simple. For reasons that are not entirely agreed upon, women in developed countries have higher life expectancy at birth, and at older ages, than do men. Women usually have an advantage in developing countries as well. However, high maternal mortality, discrimination against women in nutrition, access to healthcare, and other areas, and, in some cases, the killing or neglect of girl babies mean that, in certain poor countries, women’s life expectancy is about the same as, or even lower than, men’s. Over the next few decades, as the conditions cited above improve, women’s life expectancy in the develop- ing world is expected to increase faster than men’s. The situation in these countries will thus come to resemble that in the developed world today. This pattern has signifi cant consequences for the health of older women. To begin with, women’s long- er lifespans, combined with the fact that men tend to marry women younger than themselves and that wid- owed men remarry more often than widowed women, mean that there are vastly more widows in the world than there are widowers. Given that women in many countries rely on their husbands for the provision of  Some of this diff erence is the result of men’s higher mortality from causes which, in theory at least, should be preventable: lung cancer, alcohol-related conditions, accidents, violence, suicide, cardiovascular diseases. This fact off ers some hope that men need not forever have shorter average lifespans than women. economic resources and social status, this means that a large percentage of older wom- en are at risk of dependency, isolation, and/or dire poverty and neglect. Moreover, even if women on average live more years than men, many of these years may be spent in the shadow of disability or illness. Indeed, if “healthy life expectancy” – that is, expected years of life “in full health” – is examined in place of overall life expect- ancy, women’s advantage over men often becomes smaller (Figure ). A further consequence of differential life expectan- cy is that there are simply more older women in the world than older men – espe- cially among the “oldest old,” those 85 years of age and above (Figure ). Given that disability rates rise with age, this means that there are substantially more older women than older men living with disabilities. Despite these facts, however, common gender norms mean that it is women, not men, who are most likely to take care of needy relatives. Thus, it is not an uncom- mon occurrence for an older woman who is disabled, has lost her husband, and has no one to take care of her, to nevertheless be caring for others. Crisis situations can disproportionately aff ect older people – especially older women. Crises such as war, forced migration, famine, and the / epidemic tend both to disrupt the fabric of society in general, and to either kill or dislocate adults at their most productive ages. These situations can adversely impact older people in at least two ways: () by removing younger workers and wage earners – the basis of support on which many older people must rely in the absence of public social insurance schemes; and () by leaving in their wake orphaned, sick, and disa- bled people who must be cared for. Older women are especially aff ected by both outcomes – on the one hand, because they generally control fewer econom- ic resources than older men, and thus must rely more heavily on the support of younger adults; and, on the other, because the care of needy children and others is most likely to fall to them, in the absence of young- er women to do the job. Thus, even when a given old- er person is not herself killed in a war, for example, or infected with , she is still likely to be severely aff ect- ed by such crises. Current societal arrangements tend to make women less powerful than men, and less able to advocate for their own health. An important theme running through what has been said above is that the gender situation in most socie- ties negatively aff ects women’s power and independ- ence. Thus, for example, women’s incomes are almost always lower than men’s, and there are many more wom- en than men among the world’s poor. Social insurance schemes usually implicitly exclude the many women who work at home or in the informal sector. Societies often tolerate intimate-partner violence against wom- en. Girls often get less schooling than boys. Property ownership and inheritance, ability to move about in public as needed, authority to give informed consent and make important decisions, confi dence and a sense of self-worth – women’s access to each of these may be restricted by current societal arrangements. Figure : Overall life expectancy at birth vs. healthy life expectancy at birth: selected countries 0 10 20 30 40 50 60 70 80 90 Egypt India Netherlands 0 10 20 30 40 50 60 70 80 90 Egypt India Netherlands Overall life expectancy (years) Healthy life expectancy (years) 56 57 52 51 69 71 65 69 60 63 75 81 Male Female Figure : Number of men and women 65 and older, worldwide, by age group, 2000 (in millions). WORLD HEALTH ORGANIZATION 20, Avenue Appia Geneva, Switzerland The implications for older women’s health are neg- ative. To begin with, in her earlier years it may mean that a woman is unable to seek or receive needed med- ical treatment, that she subordinates her health needs to those of her family, that she has limited opportuni- ty to form social contacts, that she suff ers injuries and other health problems from violence, that she receives inadequate nutrition, and/or that she either does not get enough exercise or spends her time in hard physical labour. Each one of these can lead to illness and disabili- ty in later years. Once she is older, it may mean that the death of her husband leaves her with no means of sup- porting herself, let alone of receiving adequate care. What research is needed?  It is often surprisingly diffi cult to fi nd out if a given health problem has diff erent incidence, prevalence, or mortality among men as compared to women, since health data are not always presented disaggregated by sex. Even if they are, gender analysis – that is, analy- sis of the diff erent implications and context of a giv- en disease for men as compared to women – is often left out of research studies. Both of these situations must be rectifi ed if our understanding of the inter- sections of gender, health, and ageing is to grow.  Most research on ageing and health has been done in developed countries. Older people in the developing world, however, may have diff erent problems, such as infectious disease and obstetrical sequelae, or the wide- spread lack of social insurance protections and the ero- sion of traditional family patterns. Additional relevant research must be conducted in the developing world.  Since ill health and mortality in old age often stem from events and occurrences much earlier in life, lon- gitudinal studies on ageing and health should be con- ducted.  It is not clear whether older women do, in fact, suf- fer more mental illness than older men, or if this is an artefact of gendered behaviour in doctors and patients. Answering this question is important, not least because it may help in addressing the high sui- cide rates of older men.  Although it is clear that women, including older wom- en, take primary responsibility for the care of others in homes and communities, few studies quantify the extent of their contribution and the ways it can aff ect women’s own health and disability in later life. Doing so is a priority – especially as cost-cutting eff orts in health systems around the world usually rely on such “free” care. What are the implications for programmes addressing the health of older people?  The groundwork for a healthy old age is laid much earlier in life. An excellent way to improve the health of older people is to reduce smoking, improve nutri- tion, promote exercise, minimize accidents and back- breaking physical labour, ensure prevention and prop- er treatment of medical problems, and provide access to economic resources and education in the general population.  To eff ectively reach older people, interventions must take account of gender realities. The many restric- tions on women’s power and autonomy detailed above mean that older women will sometimes have more diffi culty than older men in accessing public servic- es such as healthcare. On the other hand, for certain conditions – mental health problems, for example – gender norms may make it more diffi cult for men to come forward. The ways in which gender aff ects peo- ple’s capacities and behaviour must be examined and addressed if interventions are to be eff ective.  Quality of life, not just quantity, must be a priority. A focus on mortality and overall life expectancy can obscure the fact that a longer life is not necessari- ly a blessing if it is burdened with disability, disease, dependency, or abuse. Thus, intersectoral Active Ageing policies to ensure a high quality of life, par- ticipation, health, and security – which include guar- anteeing adequate incomes, reducing the burden of caretaking expected of older women, helping older people to live with sensory and physical impairments, and providing dignifi ed living options that allow for interpersonal connection – must be part of health programmes directed towards the elderly. The use of statistics such as the “” – a measure of healthy life expectancy – should be encouraged over the use of simple overall life expectancy scales.  Interventions in crisis situations must consider the elderly. Since older people, perhaps especially older women, may experience severe adverse eff ects from crises even if they themselves are not killed, injured, or infected, interventions to deal with such situa- tions should actively seek to identify and address their needs. Department of Gender and Women’s Health Unit of Ageing and Life Course Designed by Inís – www.inis.ie © World Health Organization, 2003 • All rights reserved  See Active Ageing: A Policy Framework (http:// whqlibdoc.who.int/hq/2002/WHO_NMH_NPH_02.8.pdf; WHO, 2002) for more information on Active Ageing concepts and approaches. . situations must be rectifi ed if our understanding of the inter- sections of gender, health, and ageing is to grow.  Most research on ageing and health has been done in developed countries developing world.  Since ill health and mortality in old age often stem from events and occurrences much earlier in life, lon- gitudinal studies on ageing and health should be con- ducted actively seek to identify and address their needs. Department of Gender and Women’s Health Unit of Ageing and Life Course Designed by Inís – www.inis.ie © World Health Organization, 2003 •